Homer: rest in peace

clare & homer

Sad news for the many friends of Homer the cat.  He had developed an untreatable abdominal lymphoma, and yesterday the heartbreaking decision to euthanise him was made.

Being officially my cat, he has been buried in our back garden, though he never really regarded our property as his home.  After many wanderings he settled with my mother Clare (pictured) and they spent several happy years together until she died in 2015. After that he chose to live in turn with two younger couples, both of whom cared for him lovingly and are devastated by his loss.

To read more about Homer’s remarkable life, search for his name on this blog.

Wounded healers

During my medical career I met several doctors and nurses who had achieved excellence in their work despite – or maybe because of – health  difficulties of their own. I am sure I could not have coped so well as they did, but my recent experiences of the patient’s role have made me wonder what it would have been like if I was still in practice.

The term “wounded healer” is usually attributed to Carl Jung, who used it in a psychological context. Many of those who choose psychotherapy or counselling as a career are seeking, consciously or not, to cure problems of their own. If they have insight into these and have taken steps to resolve them, it may make their work more effective. If not, they risk causing further damage to their clients.

The term is also associated with Chiron, a figure from Greek mythology, who suffered from a chronic physical wound as the result of a poisoned arrow. He was able to heal other people but could never cure himself. I don’t know how Chiron felt about this, but many of today’s clinicians would be embarrassed by such a scenario – in line with the mantra “physician heal thyself”, there is a widespread assumption that healthcare professionals should not be ill themselves. Some patients do lack confidence in staff who have something evidently wrong with them. Others feel comforted to know that their attendants are vulnerable to the same ills as the rest of humanity, and encouraged to see them overcoming their limitations and carrying on their careers.

Compared to those in robust health, clinicians with personal experience of ill-health tend to be more sensitive and empathic, which within limits is a good thing but if taken too far can lead to over-involvement, excessive self-disclosure, loss of objectivity, and emotional exhaustion.

There is also the question of fitness to practise. There are both legal and ethical imperatives to give equal opportunities to those with illness or disability, and not discriminate against them. At the same time it must be acknowledged that they may be less capable of work than their healthy peers. Every case is different depending on the skills required in the specialty concerned, the nature of the physical and/or mental symptoms, and the time course of the condition – whether there is a chronic but stable handicap, or an episodic illness with recovery in between attacks. Whatever the diagnosis, it is likely that stamina will be impaired.

The main points that stand out from my own experience of the patient’s role relate to communication. I realised first-hand what a big impact the words of a healthcare professional can make; a casual or clumsily phrased statement regarding diagnosis or prognosis can stick in the patient’s mind, whether instilling fears that may prove unfounded, or providing reassurance that turns out to be false. Also, that the position of the patient’s relatives needs to be acknowledged, and considered in management of the case. Of course I knew about these things before, though I don’t recall being taught anything about them in my medical school days, and did not fully appreciate them till later in my career. Today’s students get more training in “soft” topics like communication skills, and hopefully do not need to wait till they or their loved ones are seriously ill to understand their importance.

Murder in the Library

Last night, along with two of the other authors entered for this year’s Ngaio Marsh Award, I had the pleasure of taking part in a “Murder in the Library” event in Takapuna. Besides describing our own books, we discussed some questions about crime fiction in general.

My husband came along for moral support but he is not a fan of this genre, and had asked me privately why on earth people enjoy reading novels about something so unpleasant as murder. I agree it is a challenge for writers to create entertainment out of such a serious subject. But crime novels are enduringly popular, and I think there are several reasons for this. They have a clear structure and focus, with a mystery to be solved and a solution at the end. They can provide insights into criminal psychology, and raise ethical and moral issues. The good ones have interesting characters and settings as well as convincing plots.

The crime genre as broadly defined covers novels of many different kinds. The traditional whodunnit, often featuring a private detective who is more competent than the police, begins with discovery of a body and ends with unmasking of the killer – usually the most unlikely of suspects from a circle of middle-class characters. This format may now seem old-fashioned but the books of “Golden Age” writers such as Agatha Christie are still very readable. Modern sub-genres of crime fiction are many: cosy, hard-boiled, police procedural, courtroom, spy, psychological thriller, and “noir” from diverse places including Scandinavia, Scotland and New Zealand.

There may be an overlap with other fiction genres, as with my own entry Unfaithful unto Death which combines crime with black comedy, and touches on the themes of corruption in medicine and the pharmaceutical industry. It could almost qualify as a historical novel, because I wrote the first draft in the 1980s following a spell of working as a doctor in general practice in rural England. I had nearly forgotten about the manuscript until I found it among some old papers last year. Reading it through again, parts struck me as rather outrageous compared to my more recent work, and the practice of medicine has certainly changed a great deal since it was written. All the same I decided to publish it without changing the content too much.

The protagonist is Dr Cyril Peabody, who also made a brief appearance in my other two 1980s novels. He is a clever and hard-working doctor who means well but has developed a hefty dose of the arrogance and cynicism which besets his profession, and his bedside manner is appalling. Having failed to gain promotion as a hospital cardiologist because of his awkward personality, he takes what he considers to be an inferior position as a country GP. Predictably he soon clashes with his partners, his patients and his wife. He sets out to improve his status by mounting a trial of a new drug, but finds it has some unexpected side effects. One of the men who has been taking it dies, apparently from a heart attack. Cyril is called to his house in the middle of the night. Having examined the body and considered the history he decides that a post-mortem is indicated, but encounters vehement opposition from the dead man’s wife …

As discussed in a previous post the medical setting provides ample scope for murder both in fiction and in real life.

Medical murder in fact and fiction

Having one of my medically themed crime novels entered for this year’s Ngaio Marsh Award has led me to reflect on the topic of murder in healthcare settings.

Deliberate killings by doctors or nurses, though rare, are probably more common than can ever be known. Clinical staff are better placed than most people to get away with murder. They have ready access to drugs, anaesthetic gases and surgical instruments, and deaths due to these agents can easily be passed off as natural or accidental. They are privileged to know intimate details of their patients’ lives. And as members of trusted professions they are not readily suspected.

Among the most notorious murderers of modern times was Dr Harold Shipman, who incidentally trained in the class ahead of me at medical school in Leeds in the 1960s. He was found guilty in a court of law of murdering 15 patients in his single-handed general practice and it is likely that he killed many more over his long career, usually by injecting large doses of diamorphine. The estimated number of his victims was 250, most of them being elderly women who were in good health although he fabricated a diagnosis of serious illness on their records. The nature of the mental aberration that led him to commit all these crimes is unknown, because he continued to deny them up until the time he hanged himself in his prison cell. As a result of Shipman’s case, much stricter controls were imposed on medical practice in the UK.

Other convicted serial murderers from medical settings have been nurses, popularly dubbed “angels of death”, working in hospitals or care homes. Their crimes usually masqueraded as mercy killings, but rather than arising from any genuine sense of compassion for someone whose incurable illness was causing unbearable suffering, they were committed for the perpetrators’ own satisfaction and without the knowledge or consent of the victims or their relatives.

Psychiatric evaluation of medical murderers would usually lead to a label of psychopathy, or personality disorder: the lack of moral sense, the inability to feel empathy, the enjoyment of killing, the grandiose belief of having a right to decide that certain persons are not fit to live. These are the extremes of the arrogance, cynicism and wielding of power that are occupational risks in medicine and related professions. Hallucinations and delusions secondary to psychosis or drug abuse are sometimes implicated.

Most if not all murderers are found to have a psychiatric diagnosis of some kind, and this may be sufficient to explain their crimes. In the context of fiction, however, using mental disorder as the sole reason for killing would usually be seen as a cop-out. Readers of crime novels expect a murder mystery to have a more complex solution,  perhaps involving money, sex, revenge, or concealment of discreditable secrets. These motives may of course account for real-life cases too.

Some would say there is a fine line between deliberate criminal killings and the various other forms of unnatural death that can occur through the actions of medical personnel. Some result from malpractice, others are sanctioned by law in certain jurisdictions. They include euthanasia, abortion, execution, experiments such as those carried out in Nazi Germany, drugs or surgery used inappropriately for commercial gain, and simple carelessness or incompetence.

My novel Unfaithful unto Death is intended as a light read with elements of black comedy, but touches on some of these serious themes.

Daisy’s renal function

I took Daisy, our 15-year-old cat, to the vet to have her long sharp front claws trimmed. She had taken to jumping up on the bed every morning, expressing her desire for food and attention by scratching my forearms hard enough to make them bleed. The vet recommended a geriatric health screen. Daisy was kept in the clinic all day for blood and urine tests, and the results showed that her renal function was somewhat impaired. I agreed to another blood test to assess the extent of the problem.

Renal (kidney) failure is very common in older cats. The many possible causes include urinary infections and ingestion of poisons. In many cases no specific cause can be found, though I wonder if processed food is implicated, for example cats fed on dry biscuits may get too much salt and not enough water. Our own cats certainly love dry biscuits, but I have always limited their intake, and fed a mixed diet with moist canned food and fresh meat, poultry or fish. The symptoms of renal failure can include increased thirst, increased urine volume, loss of appetite and weight, vomiting, diarrhoea, and general weakness. It is sometimes associated with other conditions such as anaemia, hypertension and hyperthyroidism.

Although diet is an important aspect of management, according to my reading there is some controversy around this. The standard prescription foods are low in protein, but some experts recommend feeding plenty of protein from fresh high-grade animal sources. Medication may delay progression of the condition. Adequate fluid intake is important, and severe acute cases may need parenteral fluids. Some specialised centres even offer renal dialysis and kidney transplantation.

Daisy’s second blood test showed that her renal function was “borderline”. She appears very well and has none of the symptoms listed above. After a long discussion with the vet we agreed not to initiate drug treatment or a special diet at this time.

I was about to leave the clinic when I checked on her claws and found that they had forgotten to trim them, so she was taken back to have that done. It had turned out a very expensive manicure; I could have tried to do it myself at home, though I am sure she would have scratched me.

Whether investigation of Daisy’s renal function has been worthwhile, only time will tell. Both in veterinary and in human medicine, screening for disease has pros and cons. Sometimes it does pick up a serious condition for which early treatment is desirable and even life saving. But modern tests are so sensitive that they often detect very minor abnormalities, prompting further investigations which can involve a great deal of discomfort, anxiety and expense and usually prove to have been unnecessary. On several occasions I myself have had blood results, X-Rays or biopsies reported as “borderline” or “suspicious” that eventually turned out to have been false alarms.

Daisy lying back

Blondstar: Thinking inside the box

My beautiful new yellow Honda Jazz RS has various high-tech features that were not present on my previous 10-year-old model. These include “keyless entry with remote central locking and immobiliser” which, despite studying the manual, I have found hard to understand. Judging by the posts on the internet forums for Jazz owners I am not alone in this. I read one story about a person being locked out of their car after leaving the keys inside.

After returning from a drive one night, my husband and I had only just got out of the parked car when I decided to go back and move it forward, to make more room for a neighbour’s vehicle. Leaving my husband to wait on the pavement holding my handbag, which contained the key, I popped back in and repositioned the car slightly. I switched off the engine and opened the door, but heard a series of alarming bleeps. I concluded that I should not have been driving without having the key with me. I retrieved it from my handbag and attempted to lock the car but this did not work. Then I tried various things which made the situation worse: the side lights and all internal lights came on and I could not switch them off, nor could I start the engine, and the bleeping continued whenever I opened the door. It was getting late and I dared not leave the vehicle unlocked overnight with its battery running down. I rang the AA.

The AA officer arrived by midnight, having had a long journey from another part of Auckland, and informed me that I had left the vehicle in Drive instead of Park. He was admirably kind and polite, but I was mortified and felt like an elderly version of Blondstar. Because of my fixed assumption that the problem involved the “keyless entry with remote central locking and immobiliser”, I had never thought to check for other obvious explanations.

How many mistakes, misunderstandings and lost opportunities result from being stuck in a certain mindset and failing to consider the alternatives? For example I have known several people whose serious medical conditions – for example brain tumour, Parkinson’s disease, hypothyroidism – remained undiagnosed until a late stage, because their symptoms were assumed to be due to a recurrence of the depression from which they had suffered in the past. Conclusions based on past experience, preconceived beliefs or assumptions are often correct but sometimes not, so it is a good idea to think “laterally” or “outside the box”.

Incidentally my Jazz was back in good form the day after its traumas.

car

“Across a Sea of Troubles”

Following on from my previous post about Writing a medical memoir, here is a short extract from my new book Across a Sea of Troubles.

***

“I don’t feel very well,” said my husband Brian, and slumped down on a nearby chair. His eyes were rolling upwards so that the whites were showing, and his face was very pale.

I said “I’ll call the ambulance.”

“No.”

It was a fine spring night and we were on Devonport Wharf, having just got off a late ferry from downtown Auckland. We had been attending a ballet performance of A Midsummer Night’s Dream with my mother, Clare, in celebration of her recent 91st birthday. It had been a pleasant relaxing evening and Brian had seemed perfectly alright at the theatre, but now he looked very ill indeed.

Again I proposed the ambulance, and again Brian refused, insisting that he wanted to go home. I looked around for assistance but we were alone on the wharf, my mother having gone on ahead to her own house with some neighbours we had met on the ferry.

I helped Brian onto the bus which took us halfway home, and while we slowly walked the rest of the way, I supported him as he swayed from side to side and had to keep stopping to rest.

At last we reached our house. I turned the key in the front door. As it swung open, Brian fell against it and collapsed unconscious in the hall.

I rang 111. The operator asked me a few questions and told me to check the pulse in Brian’s neck; it was around 200 beats per minute and irregular. She said that help was on its way. Meanwhile Brian had woken up and I sat beside him on the floor until the St John ambulance arrived.

The two ambulance officers helped Brian to move onto a couch, inserted a venous cannula into his arm, and ran an ECG which showed fast atrial fibrillation with left bundle branch block and ischemic changes. After making a telephone call they put up a drip and started an infusion of amiodarone, a drug that slows the heart rate and is used for the control of cardiac arrhythmias.

Brian, having a medical background, was apparently taking a detached interest in the proceedings. But when it became clear that preparations to take him to hospital were underway, he said “I’m not going.”

The senior ambulance man told him “You’re probably going to die if you don’t, mate.”

Brian continued to refuse, until I kneeled at his side and begged him to accept any treatment which might save his life. Then he suddenly said “Oh, alright.” Afterwards, he told me that he had not felt any pain or distress and would not have minded dying.

The local fire brigade came to help carry Brian down the garden steps and into the ambulance, and we set off on the first of the six urgent visits to North Shore Hospital that I was to make over the next few months.

***

Links to book: Smashwords, Amazon US, Amazon UK.

ast-smashwords-cover